Provider Demographics
NPI:1154072395
Name:LAURIE B TEAL INTEGRATIVE WELLNESS NP IN PSYCHIATRY, PLLC
Entity Type:Organization
Organization Name:LAURIE B TEAL INTEGRATIVE WELLNESS NP IN PSYCHIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:TEAL
Authorized Official - Suffix:
Authorized Official - Credentials:NPP
Authorized Official - Phone:518-812-6842
Mailing Address - Street 1:725 JUNIPER SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:SHUSHAN
Mailing Address - State:NY
Mailing Address - Zip Code:12873-2910
Mailing Address - Country:US
Mailing Address - Phone:518-812-6842
Mailing Address - Fax:518-338-0174
Practice Address - Street 1:725 JUNIPER SWAMP RD
Practice Address - Street 2:
Practice Address - City:SHUSHAN
Practice Address - State:NY
Practice Address - Zip Code:12873-2910
Practice Address - Country:US
Practice Address - Phone:518-812-6842
Practice Address - Fax:518-338-0174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05050748Medicaid